Analysis of The Anti-Viral Potential of Nasal Spray Constituents Against

bioRxiv preprint doi: https://doi.org/10.1101/2020.12.02.408575; this version posted December 21, 2020.
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Journal: TBD
Type: Original Research (Basic Science)
Abstract: 287
Text: 1486
In Vitro Analysis of the Anti-viral Potential of nasal spray constituents against
SARS-CoV-2
Mark L Cannon DDS1,2*; Jonna B. Westover, Ph.D.3; Reiner Bleher, Ph.D.4; Marcos A. Sanchez-
Gonzalez, M.D., Ph.D5.; Gustavo Ferrer, M.D.6,7
1
Department of Otolaryngology Division of Dentistry, Feinberg School of Medicine, Long Grove
IL USA
2
Ann and Robert Lurie Children’s Hospital of Chicago,, Chicago, IL, USA
3
Institute for Antiviral Research, Utah State University, Logan, Utah, USA
4
Department of Materials Science & Engineering, Northwestern University, Evanston, IL, USA
5
Lake Erie College of Osteopathic Medicine, Bradenton, FL, USA
6
Medical Innovations, Nova Southeastern University, Davie, FL, USA
7
Research & Development, Aventura Pulmonary Institute, Miami, FL, USA
*Correspondence:
Mark L. Cannon, DDS

Grove Medical Center Suite 308
4160 IL 83
Long Grove Illinois 60047
1-312-926-3264
cannon.markl@comcast.net
bioRxiv preprint doi: https://doi.org/10.1101/2020.12.02.408575; this version posted December 21, 2020. The copyright holder for this preprint
Abstract
Viral pandemics have taken a significant toll on humanity and the world now is
contending with the SARS-CoV-2 epidemic. Readily available economical preventive measures
should be immediately explored. Xylitol has been reported to reduce the severity of viral
infections as well as the severity of pneumonia, and increase the survivability of animal subjects.
Since pneumonia and acute respiratory distress syndrome are potentially fatal complications of
COVID-19, the present study tested the in vitro effectiveness of xylitol against SARS-CoV-2.
Virus titers and LRV of SARS-CoV-2, were incubated with a single concentration of nasal spray.
Toxicity was observed in the top dilution (1/10). Virus was seen below that dilution so it did not
affect calculations of virus titer or LRV. After a 25-minute contact time, the nasal spray (11%
Pure Xylitol, 0.85%NaCL (Saline), and 0.20% grapefruit seed extract) reduced virus from 4.2 to
1.7 log10 CCID50 per 0.1 mL, a statistically significant reduction (P<0.001) of 2.5 log10
CCID50. STEM Images obtained at the BIoCryo Laboratory revealed virus contained on the cell
wall but none intra-cellular, possibly due to D-xylose (xylitol) production of glycoaminoglycans
decoy targets. Xylitol and grapefruit seed extract are not exotic nor expensive rare high
technology answers to viral epidemics. The potential in saving lives and the economies of the
world by using X-GSE combination therapy should inspire large clinical trials, especially in
those nations whereas the healthcare system would be dangerously compromised by the adoption
of less effective and significantly more financially demanding therapies. Because there are no
risk factors in using the X/GSE combination therapy, and the nasal spray is over the counter
available without a prescription, and the spray allows for comfortable long term mask-wearing,
adoption of this preventive anti-viral therapy should be encouraged.

Introduction
Viral pandemics have taken a significant toll on humanity and the world now is
contending with the SARS-CoV-2 epidemic. As of November, 28st, 2020, the estimate of cases
and related fatalities for the world are reported as 61,877,685 and 1,447,246 respectively.1 The
societal cost of COVID-19 is very difficult to measure, but millions have lost their livelihoods
and the Federal (USA) expenditures top 3 trillion dollars, more than the amount spent on all
scientific research in the history of federal expenditures.2 And yet there is little to show for this
Herculean effort and expenses as of this date. For example, the total cost of World war II was 4
trillion dollars in today's dollars over 4 years with 481,000 fatalities for the United States of
America.3 It appears that more Americans will die early in just one year due to the COVID-19
epidemic. Readily available and economical preventive measures should be immediately
explored.
Newly published research has demonstrated the antiviral properties of polyols. Xylitol
has been reported to reduce the severity of viral infections. The effect of dietary xylitol on hRSV
infection was investigated in a mouse model with significant results reported.4 The mice received
xylitol for 14 days before virus exposure and for a further three days post-viral exposure. The
mice receiving xylitol had significantly reduced viral lung titers than the controls receiving
phosphate-buffered saline (PBS). Fewer CD3+ and CD3+CD8+ lymphocytes, whose numbers
are indicative of inflammatory status, were recruited in the mice receiving xylitol. These results
demonstrated improved hRSV infection outcomes and reduced inflammation-associated immune
responses to hRSV infection with dietary xylitol. The same researchers previously reported
positive effects of xylitol on mice with influenza A virus infection (H1N1) also with a decrease
in recruitment of inflammatory lymphocytes.5 It has been reported that a decrease in

CD3+CD8+ lymphocytes is a predictor of mortality for COVID-19 patients. The anti-
inflammatory and antiviral properties of D-xylose/xylitol in respiratory conditions are subject to
a patent application (number WO1999048361A1) filed in 1998 in the United States. 6
Subsequently, xylitol is a main active ingredient in nasal spray products, such as Xlear Sinus
Care.
Xylitol has also been demonstrated to reduce the severity of pneumonia, and increase the
survivability of animal subjects.7, 8 Pneumonia and acute respiratory distress syndrome are
potentially fatal complications of COVID-19. 9 Interestingly, xylitol has been used in clinical
trials to decrease Pseudomonas aeruginosa in patients with cystic fibrosis.10, 11 The idea of using
xylitol in the ventilators dedicated to COVID-19 patients was not, however, put into practice due
to the number of clinical trials with other funded treatments that later demonstrated limited
success. 12 Further research into the effectiveness of xylitol against SARS-CoV-2 is therefore
required.
Materials and Methods
Virucudal Assay
SARS-CoV-2, USA-WA1/2020 strain, virus stock was prepared before testing by growing in
Vero 76 cells. Culture media for prepared stock (test media) was MEM with 2% fetal bovine
serum and 50 μg/mL gentamicin. The compound was mixed directly with virus solution so that
the final concentration was 90% of the compound preparation and 10% virus solution. A single
concentration was tested in triplicate. Test media without virus was added to one tube of the
prepared compound to serve as toxicity controls. Ethanol (70%) was tested in parallel as a
positive control and water only as a virus control. Solution and virus were incubated at room
temperature (22 ± 2°C ) for 25 minutes. The solution was then neutralized by a 1/10 dilution in
test media.
Surviving virus from each sample was quantified by standard end-point dilution assay.
Briefly, samples were serially diluted 1/10 in test medium. Then 100 μL of each dilution were
plated into quadruplicate wells of 96-well plates containing 80-90% confluent Vero 76 cells.
Plates were incubated at 37 ± 2°C with 5% CO2 for 6 days. Each well was then scored for the
presence or absence of virus. The end-point titers (CCID50) values were calculated using the
Reed-Muench (1948) equation. Three independent replicates of each sample were tested, and the
average and standard deviation were calculated. Results were compared with untreated controls
by one-way ANOVA with Dunnett’s multiple comparison tests using GraphPad Prism (version
8) software. Controls: Virus controls were tested in water and the reduction of virus in test wells
compared to virus controls was calculated as the log reduction value (LRV). Toxicity controls
were tested with media not containing virus to determine if the samples were toxic to cells.
Neutralization controls were tested to ensure that virus inactivation did not continue after the
specified contact time, and that residual sample in the titer assay plates did not inhibit growth
and detection of surviving virus. This was done by adding toxicity samples to titer test plates
then spiking each well with a low amount of virus that would produce an observable amount of
CPE during the incubation period.
Electron Microscopy
Cell pellets were fixed in 3% glutaraldehyde, 2% formaldehyde in 0.1 M PIPES, pH 7.2
for 72 hours. After fixation, cells were enrobed in 10% gelatin, rinsed in 0.1 M PIPES for 3 x 10
minutes and postfixed in 1% osmium tetroxide for 1 hour. After two rinses for 10 minutes in DI
water, cells were en bloc stained with 2% uranyl acetate in DI water and rinsed 2 x 5 minutes
with DI water. Samples were dehydrated in an ascending series of ethanol (25%, 50%, 75%,
95% and 3 x 100%) for 15 minutes each and infiltrated at RT with EMBed 812 resin/ethanol
mixture 1:1 for 30 minutes, 3:1 for 60 minutes, and with pure resin overnight. The next day,
samples were transferred into fresh resin in silicon molds and polymerized at 65 C for 48 hours.
Sections of ca. 80 nm thickness were generated with a diamond knife (Diatome, Hatfield, PA)
using a Leica Ultracut-S ultramicrotome. The sections were placed on TEM grids and images
were recorded with a Hitachi HD2300 STEM at 200 kV acceleration voltage.
(Chemicals were from EMS, Hatfield, PA)

Glutaraldehyde 25% EMS 1x10 mL #16200
Formaldehyde 16% EMS 1x10 mL #15700
PIPES buffer EMS 450 mL #11610
EMBed812 EMS Kit #14750
Grids: EMS #G200-Cu
Results
Virucidal Assay
Virus titers and LRV of SARS-CoV-2, when incubated with a single concentration of
nasal spray, are shown in Table 1. Toxicity was observed in the top dilution (1/10). Virus was
seen below that dilution so it did not affect calculations of virus titer or LRV. After a 25-minute
contact time, the nasal spray reduced virus from 4.2 to 1.7 log10 CCID50 per 0.1 mL, a
statistically significant reduction of 2.5 log10 CCID50. Neutralization controls demonstrated that
residual sample did not inhibit virus growth and detection in the endpoint titer assays. Virus
controls and positive controls performed as expected.

Imaging
Scanning transmission electron microscope Images obtained at the BIoCryo Laboratory
(Northwestern University) revealed virus contained on the cell wall but none intra-cellular,
possibly due to D-xylose (xylitol) production of glycoaminoglycans decoy targets. A very
recently published article correlated d-xylose and xylitol to the severity and morbidity related
factors in COVID-19. 13 D-xylose is the initiating element for sulfated glycosaminoglycans
(GAG) that attach to the core protein. D-xylose can be derived from xylitol by d-xylose
reductase action replenishing this carbohydrate that is targeted by the SARS-CoV-2 virus. If the
virus attaches to the d-xylose position on the GAG, such as heparin sulfate, the virus can then
contact the ACE2 receptor. Additionally, xylitol serves as a decoy target for the virus, preventing
it from successfully reaching the ACE2 receptor. Further research into the mechanism that
xylitol initiates with cells to prevent viral penetration and replication is essential and should be
prioritized.
Discussion
Xylitol has a long history of being safe and beneficial in preventing bacterial pathogen
infections.14 It is considered a prebiotic due to its positive effect on the microbiome, reducing
pathogenic proliferation.15 The use of xylitol in oral health to prevent dental caries and
periodontal disease has been well documented as safe and effective.16, 17 Studies have shown
xylitol inhibits the formation of mixed species biofilms, which include Porphyromonas
gingivalis in vitro.16, 18 Long term clinical studies have demonstrated that children with dental
problems grow up to be adults with heart disease. For example, Kids with dental abscesses were
followed for 27 years and they developed pre-clinical signs of coronary heart disease. 19 In
addition, general morbidity and mortality rates are very closely associated with advanced
periodontal disease, and there are also well documented connections to inflammatory
Alzheimer’s disease and atherosclerosis.20-25
By inhibiting P gingivalis with xylitol and erythritol, the innate and adaptive immune
response of the human host should be more robust.26 Also, the possibility of salivary spread of
oral pathogens should be reduced, preventing onset of the acute respiratory distress syndrome.
Indeed, there have been three important recently published peer review articles, two in Medical
Hypothesis and one in the British Dental Journal that reinforce how important oral health care is
in regards to COVID-19 itself. Periodontal disease is another of the pre-disposing co-
morbidities.27 This is certainly not surprising as PD creates systemic inflammation, increase in
proinflammatory cytokine levels. This would exacerbate the cytokine storm of COVID-19, and
the oral pathogens in the saliva could cause an increase in the pneumonia risk.28
Xylitol and grapefruit seed extract are not exotic nor expensive rare high technology
answers to viral epidemics. The potential in saving lives and the economies of the world by using
X-GSE combination therapy should inspire large clinical trials, especially in those nations
whereas the healthcare system would be dangerously compromised by the adoption of less
effective and significantly more financially demanding therapies. Also, the potential mechanism
by which xylitol may pose as a decoy target for the SARS-CoV-2 virus was just recently
published. 13 Because there are no risk factors in using the X/GSE combination therapy, and the
nasal spray is over the counter available without prescription, and the spray allows for
comfortable long term mask wearing, adoption of this preventive anti-viral therapy should be
encouraged.
Conclusion
Combination therapy with GSE and xylitol may prevent spread of viral respiratory
infections not just for SAR-CoV-2 but also for future H1N1 or other viral epidemics. GSE
significantly reduces the viral load while xylitol prevents the virus attachment to the core protein
on the cell wall.
Acknowledgement
“This work made use of the BioCryo facility of Northwestern University’s NUANCE Center,
which has received support from the SHyNE Resource (NSF ECCS-2025633), the IIN, and
Northwestern's MRSEC program (NSF DMR-1720139).”

References
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9. Machhi, J., Herskovitz, J., Senan, A. M., Dutta, D., Nath, B., Oleynikov, M. D.,
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Gendelman, H. E., & Kevadiya, B. D. (2020). The Natural History, Pathobiology, and
Clinical Manifestations of SARS-CoV-2 Infections. Journal of neuroimmune
pharmacology : the official journal of the Society on NeuroImmune Pharmacology,
15(3), 359–386. https://doi.org/10.1007/s11481-020-09944-5
10. Aerosolized hypertonic xylitol versus hypertonic saline in cystic fibrosis (CF)
http://clinicaltrials.gov/ct2/show/NCT00928135?term=cystic+fibrosis+xylitol&rank=1
11. Zabner, J., Seiler, M. P., Launspach, J. L., Karp, P. H., Kearney, W. R., Look, D. C.,
Smith, J. J., & Welsh, M. J. (2000). The osmolyte xylitol reduces the salt concentration of
airway surface liquid and may enhance bacterial killing. Proceedings of the National
Academy of Sciences of the United States of America, 97(21), 11614–11619.
https://doi.org/10.1073/pnas.97.21.11614
12. Personal communications with Clinical Research sites.
13. Cheudjeu A. (2020). Correlation of D-xylose with severity and morbidity-related factors
of COVID-19 and possible therapeutic use of D-xylose and antibiotics for COVID-19.
Life sciences, 260, 118335. Advance online publication.
https://doi.org/10.1016/j.lfs.2020.118335
14. Salli, K., Lehtinen, M. J., Tiihonen, K., & Ouwehand, A. C. (2019). Xylitol's Health
Benefits beyond Dental Health: A Comprehensive Review. Nutrients, 11(8), 1813.
https://doi.org/10.3390/nu11081813
15. Lugani Y. Xylitol, An Emerging Prebiotic: A Review. International journal of Applied
Pharmaceutical and Biological Research, 2017; 2(2):67-73.

16. Janakiram C, Deepan Kumar CV, Joseph J. Xylitol in preventing dental caries: a
systematic review and meta-analyses. J Nat Sci Biol Med. 2017;8:16-21.
17. Han, S. J., Jeong, S. Y., Nam, Y. J., Yang, K. H., Lim, H. S., & Chung, J. (2005). Xylitol
inhibits inflammatory cytokine expression induced by lipopolysaccharide from
Porphyromonas gingivalis. Clinical and diagnostic laboratory immunology, 12(11),
1285–1291. https://doi.org/10.1128/CDLI.12.11.1285-1291.2005.
18. Ferreira AS, Silva-Paes-Leme AF, Raposo NRB, et al. By passing microbial resistance:
xylitol controls microorganisms growth by means of its anti-adherence property. Curr
Pharm Biotechnol. 2015;16:35-42.
19. Pussinen, P. J., Paju, S., Koponen, J., Viikari, J., Taittonen, L., Laitinen, T., Burgner, D.
P., Kähönen, M., Hutri-Kähönen, N., Raitakari, O. T., & Juonala, M. (2019). Association
of Childhood Oral Infections With Cardiovascular Risk Factors and Subclinical
Atherosclerosis in Adulthood. JAMA network open, 2(4), e192523.
https://doi.org/10.1001/jamanetworkopen.2019.2523
20. Kim J, Amar S. Periodontal disease and systemic conditions: a bidirectional relationship.
Odontology. 2006;94:10-21.
21. Dominy SS, Lynch C, Ermini F, et al. Porphyromonas gingivalis in Alzheimer’s disease
brains: evidence for disease causation and treatment with small-molecule inhibitors. Sci
Adv. 2019;5:eaau3333.
22. Kim HJ, Cha GS, Kim HJ, et al. Porphyromonas gingivalis accelerates atherosclerosis
through oxidation of high-density lipoprotein. J Periodontal Implant Sci. 2018;48:60-68.
23. Bale BF, Doneen AL, Vigerust DJ. High-risk periodontal pathogens contribute to the
pathogenesis of atherosclerosis. Postgrad Med J. 2017;93:215-220.

24. Hussain M, Stover CM, Dupont A. P. gingivalis in periodontal disease and
atherosclerosis—scenes of action for antimicrobial peptides and complement. Front
Immunol. 2015;6:45.
25. Cannon ML, Peldyak JN. The prevention and treatment of neural arterial gingival
simplex. Dental Research and Management. 2019 ;3:32-37.
26. Sánchez MC, Romero-Lastra P, Ribeiro-Vidal H, et al. Comparative gene expression
analysis of planktonic Porphyromonas gingivalis ATCC 33277 in the presence of a
growing biofilm versus planktonic cells. BMC Microbiol. 2019;19:58.
27. Pitones-Rubio, V., Chávez-Cortez, E. G., Hurtado-Camarena, A., González-Rascón, A.,
& Serafín-Higuera, N. (2020). Is periodontal disease a risk factor for severe COVID-19
illness?. Medical hypotheses, 144, 109969. https://doi.org/10.1016/j.mehy.2020.109969.
28. Sampson, V., Kamona, N., & Sampson, A. (2020). Could there be a link between oral
hygiene and the severity of SARS-CoV-2 infections?. British dental journal, 228(12),
971–975. https://doi.org/10.1038/s41415-020-1747-8.
Figure 1. SARS-CoV-2 virus outside Vero 76 immortalized cells.

Figure 2. SARS-CoV-2 on cell wall. No viral inclusion bodies noted within cell cytoplasm.
Table 1. Virucidal efficacy of nasal spray against SARS-CoV-2 after a 25-minute incubation
with virus at 22 ± 2°C.
Tested Incubation Virus

Concentration Time Titera LRV
b
Xlear Nasal Spray 90% 25-minute <0.67 3.33
Xlear Rescue Spray 90% 25-minute <0.67 3.33
XRS +50 ppm silver 90% 25-minute <0.67 3.33
XyChlor Spray, pH 6.1 90% 25-minute <0.67 3.33
Chlorhexidine 0.03% 90% 25-minute 3.67 0.33
Chlorhexidine 0.015% 90% 25-minute 3.67 0.33
Ethanol 67.5% 25-minute <0.67 3.33
Virus Control na 25-minute 4.0 na
Concentration Incubation Virus Titera LRVb
Nasal spray 90% 25-minute 1.7 ± 0.0 2.5***
Ethanol 67.5% 25-minute 1.0 ± 0.6 3.2***
Virus Control na 25-minute 4.2 ± 0.4 na
a Log10 CCID50 of virus per 0.1 mL, average of 3 replicates ± standard deviation
b LRV (log reduction value) is the reduction of virus compared to the virus control
***P < 0.001 by one-way ANOVA and Dunnett’s post-test compared with untreated virus
control (water). For wells with undetectable virus a value equal to the lower limit of detection
was assigned for statistical analyses.

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bioRxiv preprint doi: https://doi.org/10.1101/2020.12.02.408575; this version posted December 21, 2020.

The copyright holder for this preprint

In Vitro Analysis of the Anti-viral Potential of nasal spray constituents against

Gonzalez, M.D., Ph.D5.; Gustavo Ferrer, M.D.6,7

Mark L. Cannon, DDS

adoption of this preventive anti-viral therapy should be encouraged.

epidemic. Readily available and economical preventive measures should be immediately

demonstrated improved hRSV infection outcomes and reduced inflammation-associated immune

in recruitment of inflammatory lymphocytes.5 It has been reported that a decrease in

CD3+CD8+ lymphocytes is a predictor of mortality for COVID-19 patients. The anti-

inflammatory and antiviral properties of D-xylose/xylitol in respiratory conditions are subject to

a patent application (number WO1999048361A1) filed in 1998 in the United States. 6

Materials and Methods

CPE during the incubation period.

Cell pellets were fixed in 3% glutaraldehyde, 2% formaldehyde in 0.1 M PIPES, pH 7.2

were recorded with a Hitachi HD2300 STEM at 200 kV acceleration voltage.

(Chemicals were from EMS, Hatfield, PA)

controls and positive controls performed as expected.

Scanning transmission electron microscope Images obtained at the BIoCryo Laboratory

possibly due to D-xylose (xylitol) production of glycoaminoglycans decoy targets. A very

factors in COVID-19. 13 D-xylose is the initiating element for sulfated glycosaminoglycans

Alzheimer’s disease and atherosclerosis.20-25

in regards to COVID-19 itself. Periodontal disease is another of the pre-disposing co-

morbidities.27 This is certainly not surprising as PD creates systemic inflammation, increase in

on the cell wall.

Northwestern's MRSEC program (NSF DMR-1720139).”

Johns Hopkins University (JHU)- November 28th, 2020.

2. An Update to the Budget Outlook: 2020 to 2030 (September 2020),

respiratory syncytial virus (hRSV) infection. Biol Pharm Bull. 2016;39:540-546.

infection. PLoS One. 2014;9:e84633.

Intellectual Property Organization. International Publication Number: WO 99/48361.

September 30, 1999.

(2001). Effect of xylitol on growth of Streptococcus pneumoniae in the presence of

fructose and sorbitol. Antimicrobial agents and chemotherapy, 45(1), 166–169.

nutrition enhances bacterial killing and prolongs survival of rats in experimental

pneumococcal sepsis. BMC microbiology, 8, 45. https://doi.org/10.1186/1471-2180-8-45

Clinical Manifestations of SARS-CoV-2 Infections. Journal of neuroimmune

pharmacology : the official journal of the Society on NeuroImmune Pharmacology,

15(3), 359–386. https://doi.org/10.1007/s11481-020-09944-5

Academy of Sciences of the United States of America, 97(21), 11614–11619.

12. Personal communications with Clinical Research sites.

Life sciences, 260, 118335. Advance online publication.

Benefits beyond Dental Health: A Comprehensive Review. Nutrients, 11(8), 1813.

15. Lugani Y. Xylitol, An Emerging Prebiotic: A Review. International journal of Applied

Pharmaceutical and Biological Research, 2017; 2(2):67-73.

systematic review and meta-analyses. J Nat Sci Biol Med. 2017;8:16-21.

inhibits inflammatory cytokine expression induced by lipopolysaccharide from

Porphyromonas gingivalis. Clinical and diagnostic laboratory immunology, 12(11),

xylitol controls microorganisms growth by means of its anti-adherence property. Curr

Pharm Biotechnol. 2015;16:35-42.

of Childhood Oral Infections With Cardiovascular Risk Factors and Subclinical

Atherosclerosis in Adulthood. JAMA network open, 2(4), e192523.

through oxidation of high-density lipoprotein. J Periodontal Implant Sci. 2018;48:60-68.

pathogenesis of atherosclerosis. Postgrad Med J. 2017;93:215-220.

24. Hussain M, Stover CM, Dupont A. P. gingivalis in periodontal disease and

atherosclerosis—scenes of action for antimicrobial peptides and complement. Front

simplex. Dental Research and Management. 2019 ;3:32-37.

26. Sánchez MC, Romero-Lastra P, Ribeiro-Vidal H, et al. Comparative gene expression

analysis of planktonic Porphyromonas gingivalis ATCC 33277 in the presence of a

growing biofilm versus planktonic cells. BMC Microbiol. 2019;19:58.

27. Pitones-Rubio, V., Chávez-Cortez, E. G., Hurtado-Camarena, A., González-Rascón, A.,

illness?. Medical hypotheses, 144, 109969. https://doi.org/10.1016/j.mehy.2020.109969.

Figure 1. SARS-CoV-2 virus outside Vero 76 immortalized cells.